Can they crack it? The future of health services in Northern Ireland and Republic of Ireland after Brexit
With less than ayear to go before Brexit, concern over the future of cross-border collaboration after 29 March 2019 is growing
With less than a year to go before Brexit, concern over the future of cross-border collaboration after 29 March 2019 is growing
The health service was a key factor in the EU referendum campaign, but two years on from the Brexit decision, and less than one year away from the scheduled leave date, there is increasing frustration, and in some cases alarm, at the lack of clarity over how the sector will be affected.
And this frustration over the possibility of a hard Brexit, or no deal at all, is felt deeply in Northern Ireland (NI), which shares a 310-mile land border with the EU.
With a population of about 1.8 million, it would be impossible for Northern Ireland to provide some specialised health services without cooperating with the Republic of Ireland. But, unless an agreement is reached to avoid a hard border, patients who have become used to accessing services near to where they live, which is sometimes on the opposite side of the border, could instead face long journeys to receive care.
And any new restrictions could directly affect staff who regularly cross the border to care for patients or co-ordinate services. There are no official figures on how many this applies to but, given that 30,000 people in total cross the border every day, and one in seven of the population work in health services, the number could be more than 4,000.
Unique to Northern Ireland
Director of the NI Confederation for Health and Social Services Heather Moorhead says senior healthcare staff would welcome assurances that health issues, as they uniquely affect Northern Ireland, will be prioritised in the ongoing negotiations.
‘There’s much going on behind the scenes to ensure the right plans are in place, both north and south of the border but, because "nothing’s agreed until everything’s agreed”, agreements that have already been reached could come off the table if there’s a no-deal situation.’
The confederation is a member of the Brexit Healthcare Alliance, which in January brought together more than 100 healthcare leaders in Belfast for a conference to discuss the implications of Brexit. The event focused on the alliance’s five collective ‘asks’ for healthcare systems post-Brexit:
UK-wide figures show an 87% fall in new admissions to the register from EU countries between 2016 and 2018
- Maximum research and innovation collaboration.
- Regulatory alignment.
- Preservation of reciprocal healthcare arrangements.
- Robust co-ordination mechanisms on public health and wellbeing, for example involving pandemics.
- A strong funding commitment to the health and public health sectors, especially offsetting any shortfall in EU funding resulting from Brexit.
The alliance’s aim is to safeguard the interests of patients, and the healthcare and research they rely on, during and after the Brexit negotiations. Meanwhile the Cavendish Coalition, made up of 37 organisations, has similar aims, but is focusing on the workforce implications of Brexit.
In March 2017, the group discussed a briefing paper drawn up by healthcare leaders from both sides of the border, called Northern Ireland and the EU Exit: A unique set of challenges, outlining the breadth and scale of the workforce issues that need to be resolved ahead of Brexit. Key concerns included:
- Maintaining shared services.
- Adequate supply of safe and qualified healthcare staff.
- Mutual recognition of professional qualifications.
- Consistency in application of professional regulation in both jurisdictions.
But just over one year later many of those challenges remain unresolved. The Royal College of Nursing’s head of policy in Northern Ireland John Knape told RCN congress in Belfast in May that, in the face of continuing uncertainty over Brexit, nurses were voting with their feet.
‘What’s lacking at the moment in Northern Ireland, and across the UK, is any serious attempt to address the issue of the effect of Brexit on healthcare in Northern Ireland. Nurses and other healthcare workers, and patients, require some certainty on how healthcare is going to be delivered post-Brexit.’
The Nursing and Midwifery Council does not keep separate statistics for EU nurses in Northern Ireland, but UK-wide figures show an 87% fall in new admissions to the register from EU countries between 2016 and 2018. Meanwhile there has been a 29% rise in the number of EU nurses leaving the register.
In response to the growing staffing crisis, the Northern Ireland Department of Health has been running an international nurse recruitment campaign since 2016. Success has been limited, partly due to Brexit, and by May 2018 just 159 arrivals from EU and non-EU countries had found jobs. The campaign is now focusing more on non-EU nurses. Meanwhile the NI health department has set up a forum for health and social care employers to look at the ‘practical workforce consequences’ of Brexit.
But the effect of the UK quitting the EU does not stop with workforce issues.
NI chief nursing officer (CNO) Charlotte McArdle told the all-Ireland CNO conference in November 2015, just seven months before the Brexit vote, that she was greatly encouraged by what could be achieved by closer working and sharing best practice between Northern Ireland and the Republic of Ireland. She added that it was important that this partnership approach continued in an era of increased demand and financial uncertainty.
‘For more than 20 years, the cross-border Cooperation and Working Together partnership has delivered health and social care services in the border regions… and I look forward to further collaboration and sharing of best practice with our colleagues in the Republic.'
Strain on shared services
The concern is that Brexit could derail these aspirations and put a strain on those shared services and relationships.
In May the Cooperation and Working Together partnership, which promotes collaborative working across the border, announced a new €8.8 million (about £7.7 million) EU grant for cross-border services that could benefit 13,000 patients.
Clinical areas that will be modernised include dermatology, urology and vascular interventions. Some areas of unscheduled care will also be reformed including advanced community paramedic services, community cardiac investigations, the clinical decision unit in Southern Health and Social Care Trust and the community geriatrician-led services in Sligo and South Fermanagh.
It is also planned to establish an integrated clinical dermatology network using telehealth.
Other joint initiatives include:
- The all-island cardiology service at Our Lady’s Children’s Hospital, Dublin.
- The radiotherapy unit at Altnagelvin Area Hospital, part of Western Health and Siocial Care Trust.
- Ear, nose and throat treatment at Craigavon, County Armagh.
A Department of Health spokesperson pointed out that all-island services such as the Congenital Heart Disease Network and the North West Cancer Centre, at Altnagelvin Area Hospital, in Derry/Londonderry, accessed by patients from both sides of the border, are not underpinned by European regulations, but are based on intergovernmental agreements between the respective health departments, covered by service-level agreements. In both cases, patients are registered with their own health service, which pays for the cross-jurisdictional aspect.
The spokesperson added: ‘In order to ensure public services continue to operate on Day 1 following the UK exit from the EU, regardless of the negotiated outcome, all NI government departments and their arm’s-length bodies are considering the potential impact of EU exit and the actions that may need to be taken.
‘The priorities identified are the workforce issues, including the Mutual Recognition of Professional Qualifications (MRPQ), pharmacy regulation, recruitment and retention, cross-border movement of staff and access to healthcare in other EU states post-exit.’
Cooperation also underpins public health and health security, for example concerning infectious diseases, emergency preparedness and collaboration on early alerts.
The spokesperson added: ‘Both the UK and the EU have indicated that they remain committed to protecting and supporting continued north-south/east-west cooperation.’
She said that it would be ‘premature’ to form a view on the impact of Brexit at this time. ‘Planning for Day 1 will continue to be refined as we get more clarity from the negotiations and, ultimately, detail of the final agreement.’
Cross-border service arrangements have led to high-quality services, particularly in primary care, cancer care and children’s cardiac surgery. And a number of projects have been created thanks to active support from the EU working in partnership with the administrations in the UK and Ireland.
These projects have particularly benefited patients with specific clinical needs concerning diabetes, sexual health, eating disorders and autism, and they serve communities on both sides of the border, again reaching sufficient patients to secure the economies of scale needed.
The authors of Brexit and the NHS, a report by the think-tank UK in a Changing Europe, say Brexit could put the numerous cross-border initiatives that support healthcare in Northern Ireland at risk. They highlight the radiotherapy centre at Altnagelvin Area Hospital, which is accessible to patients in County Donegal, in the Republic, who would otherwise have to travel long distances to Dublin or Galway to obtain similar treatment.
EU integration has also enabled economies of scale across the Irish border. A heart facility was established in 2014 at Our Lady’s Children’s Hospital, Dublin, for children from both sides of the border.
‘Both the UK and the EU have indicated that they remain committed to protecting and supporting continued north-south/east-west cooperation’
This cooperation is made easier thanks to the EU Directive on the MRPQ and on EU rules on data protection, enabling the sharing of patient details. The hope is that access to these shared facilities and others, such as the North West Cancer Centre, can be protected under any future UK-EU relationship and even bilateral UK-Ireland arrangements covering the 'Common Travel Area', to allow for free movement of citizens.
Another issue under discussion is organ transplantation. The UK currently exports organs for transplant to other EU member states, including the Republic of ireland. Although it is hoped the free movement of transplant organs will continue, like so much else around Brexit, the future is unclear.
As Nuffield Trust policy analyst Mark Dayan states in a briefing on Brexit and Northern Ireland healthcare: ‘Difficult choices must be made. Northern Ireland’s NHS, like health services in England, Wales and Scotland, already faces flat funding, rising waiting times, staffing shortages and rising ill health. In many ways, it is in an even more difficult position than its peers.
‘What cannot be allowed to happen is for the conundrums of Brexit to be allowed to spill over, unresolved, into affecting the delivery of health and social care.'
However, current uncertainty is already ‘spilling over’ and having an effect, and, as the EU leave date of 29 March 2019 looms ever closer, the question is: what can be done to avoid healthcare services being disrupted, now and in the future? At the moment that question remains unanswered.
View from the front line
For staff such as Linsey Sheerin, clinical co-ordinator for the emergency department at the Royal Victoria Hospital, Belfast, discussions over Brexit and healthcare are like ‘white noise’ in the background, ever present, but not always uppermost in the mind.
‘Of course Brexit is cause for concern. We have our well documented history of The Troubles so one thing for certain is that no one wishes there to be any potential risk to civil order in Northern Ireland.
‘I’m working more at an operational level at the moment so all this is not on my agenda due to existing pressures. However, strategically I am hoping the finer details are being worked out by others.
'But very little direction or information has been shared to date.
‘Too often we don’t talk about issues until we have to fire-fight the consequences. We already have an under-resourced, very stretched health system under acute pressure. We have been without a national government since January 2017, so there is no political leadership supporting or guiding us through this transition.
‘In 2016 Northern Ireland launched a ten-year blueprint to transform services but Brexit is yet another obstacle. While there may be opportunities from the changes, there will also be the administrative burden of legislation and that’s irrespective of whether it is declared a hard or soft Brexit.
‘What we all want to know is: will Brexit restrict funding of services and hold back our transformation agenda and how much harder is it going to be to deliver healthcare in Northern Ireland?’